The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 116 Results

Survey results from pharmacists provide support to enhance the organizational response to codes.

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ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.

Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.

Charlie Bourg was on the lookout for veterans harmed by a new VA computer system. He didn’t expect to be one of them.

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Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.

ERs are swamped with seriously ill patients, although many don’t have Covid.

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Wells K. Health Shots. National Public Radio. October 29, 2021.

Emergency department (ED) crowding stemming from treatment delays and deferrals resulting from COVID concerns is an emerging problem. This article discusses how ED crowding affects patients and clinical teams to reduce safety and effectiveness.

How medical jargon can make COVID health disparities even worse.

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Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Cancer diagnoses delayed among prisoners in Washington state.

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Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

L.A.’s poorest patients endure long delays to see medical specialists. Some die waiting.

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Dolan J, Mejia B. Los Angeles Times. September 30, 2020.

Socioeconomic conditions influence access to health care, and as a result, reduce its safety and reliability. This story describes how inequity can affect the care of disadvantaged patient populations and shares data on wait times for specialty care in Los Angeles County that contributed to costly diagnostic and treatment delays.

‘You’re going to release him when he was hurting himself?’

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Dahlberg B. Kaiser Health News. September 29, 2020.

This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

Sent home to die.

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Waldman A, Kaplan J. ProPublica. 2020.

Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.

Using telehealth to revolutionize the speed of making rare disease diagnoses.

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Nothaft W, Moore G, Le Cam Y. STAT. August 27, 2020.

Patients with rare diseases present diagnostic challenges. This article introduces the potential for improvements in diagnosis that telemedicine brings to the process through enabling access to appropriate expertise previously limited by geography.

Doctors turned my sister away; less than two years later she died of cervical cancer.

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Harvey-Jenner C. Cosmopolitan. August 27, 2020.

Implicit biases are known to impact effective diagnosis. This story highlights how dismissed concerns resulted in a delay in cancer diagnosis that contributed to the death of a young woman.

Missed and delayed diagnoses of non-COVID conditions--collateral harm from a pandemic.

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Carr S. ImproveDx. 2020;7:1-5.

The coronavirus pandemic has disrupted patient care seeking behaviors. This article discusses this phenomenon and its impact on the timing of diagnosis due to fear of contracting COVID-19 or threats resulting from the economic shutdown implemented to reduce spread of the virus.

Fear of Covid-19 leads other patients to decline critical treatment.

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Hafner K. New York Times. 2020;May 25.

The uncertainties surrounding coronavirus transmission and treatment are causing patients with known conditions to forgo needed medical care. This article outlines how COVID-19 fear and anxiety are primary contributing factors in patient decisions to delay transplants and other necessary treatments.

With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications.

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Brodwin E. STAT. April 14, 2020.

Patients with cancer and other chronic disorder treatment needs have been negatively affected by the restructuring of services to reduce the spread of the coronavirus. This story discusses company strategies to prepare to virtually support patients with a range of conditions. The author shares communication and support tactics to keep patients safe until they can get their appointments.

As COVID-19 bears down, doctors confront difficult choices on elective surgeries.

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Alesse L, Dukakis A, Tatum S, Mosk M. ABC News. March 20, 2020.

Delays in elective surgery and other procedures have the potential to lessen safe patient care. This news story describes the decision-making dilemma for physicians to limit patient access to care during the COVID-19 pandemic. Their concern is that the delays have the potential to result in diagnostic and treatment service deviations that could result in harm.

Broken, fragmented health-care system failed daughter who died by suicide.

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Klowak M. CBC News. March 9, 2020.

System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.

A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays.

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Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.

Delays in emergency room (ER) triage and assessment contribute to wide range of failures that degrade patient safety. This news story highlights the findings of a government report highlighting overcrowding and production pressures as factors resulting in the death of a patient waiting for care who initially presented at the ER with symptoms of heart attack.

Advancing safety with closed-loop communication of test results.

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Quick Safety. December 17, 2019;(52):1-3.

Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares recommendations to enhance handoffs and information sharing amongst care teams and with patients.

How implicit bias harms patient care.

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Bendix J. Med Econ. November 25, 2019;96(23);10-14.

Implicit biases can compromise decision making due to the effect they can have on heuristics, communication and patient/physician communication. This article shares reasons for these biases and shares tactics to minimize their impacts which include being mindful of biases and a personalized approach to patients.

A mismatch made in America.

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Butcher L. Managed Care. June 2019;28:37-39.

Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.

Perioperative medication errors: uncovering risk from behind the drapes.

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Cierniak KH; Gaunt MJ; Grissinger M.

The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.

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